ESTABLISHMENT FORM

(Order Name Of PT, Deed of Establishment, Legalization Decree/Waarmeking, NPWP, OSS RBA)

Every 1 Business Activity KBLI 5-digit number, there is a Scale and Risk Level (SIUP is eliminated).
The scale consists of:
1. Micro Business: Max 1 M. (umkm)
2. Small Business: Above 1M to 5 M. (umkm)
3. Medium Business: Above 5 M to 10 M. (non umkm)
4. Large Business: Above 10 M. (non umkm)
The aforementioned capital does not include the land and building of the business premises.

A. IDENTITY OF COMPANY
1. Name Of Company :
2. Phone Number Of Company. : (Mobile No. Allowed)
3. Company Email :
4. Investment : National Private / Foreign Investment / Investment
Domestic Capital (Cross out unnecessary ones).
5. Full Address of the Company (must be for offices or housing permitted for business premises. Error in
filling in the address is not the responsibility of the Notary):

Full Address of the Company :

RT/RW :
Village :
District :
City :
Province :
Zip Code :

B. STRUCTURE MANAGEMENT OF COMPANY

Name :
Role Position : First Director / Director
Phone Number :
Email :

Name :
Role Position : Commissioner
Phone Number :
Email :

C. PT Capital (excluding land & building) & PT Business Activities

Authorized capital: IDR.
Paid-up and issued capital (at least 25% of the Authorized Capital):
Nominal value per share: Rp.

D. PT Business Activities (enter the KBLI number which is a 5-digit number, not a 4/3/2-digit number):
(Prohibition of KBLI wholesale trade combined with retail trade in 1 PT, choose one).

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E. Composition of Shareholders of PT
Name :
Number of shares :
Phone No. :
Email :

Name :
Number of shares :
Phone No. :
Email :

The OSS RBA PT form is attached in the appendix.

Required documents:
1.Founder/shareholder:
a.If the shareholder is an individual: KTP, NPWP.
b. If the shareholder is a PT: Deed of Establishment of PT along with deeds of amendment up to the last deed
and SK & letters of the Ministry of Law and Human Rights, ID card of Directors & Board of Commissioners,
NPWP of PT.
2. KTP & NPWP of Directors & Board of Commissioners.
3. Other documents:
Scan of Lease Agreement (if the Office Domicile is Leased), Scan of Building Rights Certificate (if the Office
Domicile is Privately Owned), Scan of IMB (if required).

For and on behalf of PT.